Hospital Rankings and Health Equity

Binger, Tavia; Chen, Harold; Harder, Ben

doi:10.1001/jama.2022.19001

Cited by 15 publications

(14 citation statements)

References 8 publications

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“…35 For example, US News & World Report recently piloted a set of racial equity measures that reflect areas where hospitals have the opportunity to improve health care quality for the most vulnerable patients in their community. 36 compared with these analyses due to differences in methodology, our results are consistent with this prior work that finds that racial segregation in health care delivery is persistent, even though formal practices of racial segregation have been prohibited for decades. 4,8,9,37 Furthermore, our finding that segregation is associated with racial disparities in outcomes is consistent with prior research showing that Black surgical patients may be more likely to receive care from lower-quality providers.…”

Section: Discussionsupporting

confidence: 88%

Segregated Patterns of Hospital Care Delivery and Health Outcomes

Lin,

Hammond,

Esposito

et al. 2023

JAMA Health Forum

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ImportanceResidential segregation has been shown to be a root cause of racial inequities in health outcomes, yet little is known about current patterns of racial segregation in where patients receive hospital care or whether hospital segregation is associated with health outcomes. Filling this knowledge gap is critical to implementing policies that improve racial equity in health care.ObjectiveTo characterize contemporary patterns of racial segregation in hospital care delivery, identify market-level correlates, and determine the association between hospital segregation and health outcomes.Design, Setting, and ParticipantsThis cross-sectional study of US hospital referral regions (HRRs) used 2018 Medicare claims, American Community Survey, and Agency for Healthcare Research and Quality Social Determinants of Health data. Hospitalization patterns for all non-Hispanic Black or non-Hispanic White Medicare fee-for-service beneficiaries with at least 1 inpatient hospitalization in an eligible hospital were evaluated for hospital segregation and associated health outcomes at the HRR level. The data analysis was performed between August 10, 2022, and September 6, 2023.ExposuresDissimilarity index and isolation index for HRRs.Main Outcomes and MeasuresHealth outcomes were measured using Prevention Quality Indicator (PQI) acute and chronic composites per 100 000 Medicare beneficiaries, and total deaths related to heart disease and stroke per 100 000 residents were calculated for individuals aged 74 years or younger. Correlation coefficients were used to compare residential and hospital dissimilarity and residential and hospital isolation. Linear regression was used to examine the association between hospital segregation and health outcomes.ResultsThis study included 280 HRRs containing data for 4386 short-term acute care and critical access hospitals. Black and White patients tended to receive care at different hospitals, with a mean (SD) dissimilarity index of 23 (11) and mean (SD) isolation index of 13 (13), indicating substantial variation in segregation across HRRs. Hospital segregation was correlated with residential segregation (correlation coefficients, 0.58 and 0.90 for dissimilarity and isolation, respectively). For Black patients, a 1-SD increase in the hospital isolation index was associated with 204 (95% CI, 154-254) more acute PQI hospitalizations per 100 000 Medicare beneficiaries (28% increase from the median), 684 (95% CI, 488-880) more chronic PQI hospitalizations per 100 000 Medicare beneficiaries (15% increase), and 6 (95% CI, 2-9) additional deaths per 100 000 residents (6% increase) compared with 68 (95% CI, 24-113; 6% increase), 202 (95% CI, 131-274; 8% increase), and 2 (95% CI, 0 to 4; 3% increase), respectively, for White patients.Conclusions and RelevanceThis cross-sectional study found that higher segregation of hospital care was associated with poorer health outcomes for both Black and White Medicare beneficiaries, with significantly greater negative health outcomes for Black populations, supporting racial segregation as a root cause of health disparities. Policymakers and clinical leaders could address this important public health issue through payment reform efforts and expansion of health insurance coverage, in addition to supporting upstream efforts to reduce racial segregation in hospital care and residential settings.

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Section: Discussionsupporting

confidence: 88%

Segregated Patterns of Hospital Care Delivery and Health Outcomes

Lin,

Hammond,

Esposito

et al. 2023

JAMA Health Forum

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“…In Reply In response to our recent Viewpoint about hospital rankings and health equity, Dr Bai and colleagues note that certain hospitals may attract patients from a broader geographic base outside of the hospital service area for various reasons, including providing specialized care. To address this, US News & World Report ’s measures that examine racial and ethnic representation were limited to individuals who reside within each hospital’s service area.…”

mentioning

confidence: 99%

Health Equity and Measures Hospital Rankings—Reply

Binger

Harder

2023

JAMA

Self Cite

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To the Editor In a recent Viewpoint, 1 authors from US News & World Report described several health equity measures to be used to evaluate hospitals' performance on 3 dimensions: access, outcome, and social determinants of health. While we applaud the effort to promote health equity and ensure hospital accountability, in this Letter, we highlight some potential limitations of the effectiveness of these measures for evaluating hospitals' health equity performance.The proposed access measure captured how closely the racial composition of Medicare patients undergoing typically elective procedures in a hospital matched Medicare beneficiaries residing in the surrounding community. However, some hospitals that provide specialized care (eg, organ transplants) attract Medicare patients from a broader geographic base. In addition, patients from racial and ethnic minoritized groups may bypass a closer, higher-quality hospital to go to a more distant lower-quality hospital not because of hospital acceptance metrics but because of insurance networks-and hospitals are only one part of the decisions regarding networks. 2 To investigate outcomes disparities, hospital-level differences in the risk of 30-day unplanned readmission were examined between Black and White patients following common surgical procedures. Whether hospital readmission rate is a valid measure of quality is under debate because a given patient's probability of readmission appears heavily influenced by social determinants of health, which hospitals do not directly control. 3 Hospitals may be incentivized to take actions that reduce the racial and ethnic differences in readmission risk without improving health equity, for example, by selectively admitting healthier Black patients and avoiding admissions of individuals with unstable housing or limited social support.In addition, the proposed measure for social determinants of health was the alignment between the proportion of a hospital's cost spent on uninsured charity care and the proportion of uninsured individuals in its communities. However, hospitals provide charity care to both uninsured and underinsured patients, 4 so this measure might reduce incentives for hospitals to assist underinsured patients. Also, nonprofit and for-profit hospitals receive different taxpayer subsidies and thus have different obligations for charity care provision. 4 Organizations adjust behaviors in response to performance measures. We are concerned that the proposed hospital health equity measures outlined in the Viewpoint 1 might induce hospitals to act in ways that do not necessarily improve health equity. More understanding and refinement of these measures are needed to rigorously evaluate hospital performance and motivate hospitals to effectively enhance health equity.

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“…Although the impact of health-related social needs (HRSNs) on children’s health is well documented, there has been a recent fervor to implement HRSN screenings broadly in pediatric health care organizations, catalyzed by health equity–focused changes in the health care industry. These include Joint Commission requirements, Centers for Medicare and Medicaid quality measures, US News and World Reports hospital rankings, and efforts to incorporate screening into value-based reimbursement systems. As HRSN screening becomes standard of care, there are several implications for pediatric health care organizations as they transition from a care model that was once fully under the purview of families and frontline clinicians/staff to an approach overseen by systems-level leaders and administrators.…”

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confidence: 99%